The past and future of maternal and peripartum mortality
Authors: Maria L Costa, Renato T Souza
Journal: The Lancet Global Health (2023)

We read with great interest the study by Ties Boerma and colleagues published in The Lancet Global Health.1Boerma T Campbell OMR Amouzou A et al.Maternal mortality, stillbirths, and neonatal mortality: a transition model based on analyses of 151 countries.Lancet Glob Health. 2023; 11: e1024-e1031Summary Full Text Full Text PDF Google Scholar They report changes in maternal mortality, stillbirths, and neonatal deaths from UN estimates for 151 countries, using a five-phase mortality transition model. The authors found that 63% of 116 countries analysed progressed at least one phase in reducing stillbirths and maternal and neonatal mortality rates from 2000 to 2020. Progression was associated with a decrease in deaths due to infectious diseases and peripartum complications, along with decreasing fertility rates (particularly among adolescents), increasing per-capita health spending, and reduced out-of-pocket expenditure on health care. Antenatal care coverage and the proportion of births occurring in health facilities also increased across phases. The transition across phases initially involved more births in lower-level health facilities (rather than at home), followed by a shift to more hospital births. The five-phase mortality transition model can be used to benchmark progress, identify outliers, and inform planning and investment towards the UN Sustainable Development Goals for maternal and neonatal mortality reduction. Including the assessment of stillbirth and neonatal mortality rates is very resourceful, not only because they are closely linked to the quality of maternal health-care services, but also because they are usually neglected in global maternal health initiatives.2Frøen JF Friberg IK Lawn JE et al.Stillbirths: progress and unfinished business.Lancet. 2016; 387: 574-586Summary Full Text Full Text PDF PubMed Scopus (118) Google Scholar In the past two decades,3WHOA neglected tragedy: the global burden of stillbirths. UN Inter-agency Group for Child Mortality Estimation (IGME). World Health Organization, 2020https://cdn.who.int/media/docs/default-source/mca-documents/maternal-nb/a-neglected-tragedy-stillbirths-igme-report-english-202088522c685daf4281a2a151a9e1093111.pdf?sfvrsn=594f81e1_1&download=trueDate accessed: May 14, 2023Google Scholar stillbirth rates have been included by global initiatives, such as the UN Millennium Development Goals and WHO Every Newborn Action Plan, as a useful maternal and child health indicator or target. According to a systematic review published in 2021, global stillbirth rates reduced by 2·3% and neonatal mortality by 2·9% annually from 2000 to 2019.4Hug L You D Blencowe H et al.Global, regional, and national estimates and trends in stillbirths from 2000 to 2019: a systematic assessment.Lancet. 2021; 398: 772-785Summary Full Text Full Text PDF PubMed Scopus (84) Google Scholar Although medical interventions have substantially reduced maternal, stillbirth, and neonatal mortality rates, disparities in access and quality of care remain, especially for disadvantaged populations. These disparities are influenced by multiple factors such as the type of evidence-based health care being implemented, facility size, and place of birth (eg, home vs institutional birth, and geographical region).5Shaw D Guise JM Shah N et al.Drivers of maternity care in high-income countries: can health systems support woman-centred care?.Lancet. 2016; 388: 2282-2295Summary Full Text Full Text PDF PubMed Scopus (131) Google Scholar In many settings, over-medicalisation and its potentially harmful effects are a concern, and communication between providers and patients at facilities can be poor, which can lead to a fear of health care. Models of care that are defined as delivering too much, too soon (TMTS) or too little, too late (TLTL) are both considered suboptimal for timely access to quality care, which is associated with preventable maternal morbidity and mortality. TMTS is rapidly increasing globally, especially in the private sector, due to weak regulatory capacity and little adherence to evidence-based guidelines. TLTL happens in low-income settings and can affect vulnerable populations. To address this complex scenario, quality clinical practice guidelines need to be developed with consensus among providers, public health leaders, and social representatives, and effective and sustained implementation of evidence-based care is required. A good example of the need for evidenced-based intervention is the need for provider-initiated delivery, including preterm birth. Provision of timely prelabour caesarean section or labour induction can be a life-saving intervention for both the birthing parent and baby; however, if not supported by evidence, it can be associated with higher rates of perinatal morbidity and mortality.6Morisaki N Zhang X Ganchimeg T et al.Provider-initiated delivery, late preterm birth and perinatal mortality: a secondary analysis of the WHO multicountry survey on maternal and newborn health.BMJ Glob Health. 2017; 2e000204Crossref Scopus (4) Google Scholar The findings reported by Boerma and colleagues1Boerma T Campbell OMR Amouzou A et al.Maternal mortality, stillbirths, and neonatal mortality: a transition model based on analyses of 151 countries.Lancet Glob Health. 2023; 11: e1024-e1031Summary Full Text Full Text PDF Google Scholar represent a proof of concept of the obstetric transition phenomenon, showing the dynamic process whereby countries transition to lower rates of maternal mortality (largely driven by a reduction in direct causes of mortality) by increasing health-care access and rates of medicalisation (eg, antenatal care visits, deliveries in hospital, and caesarean sections). As conceptually proposed in 2014,7Souza JP Tunçalp Ö Vogel JP et al.Obstetric transition: the pathway towards ending preventable maternal deaths.BJOG. 2014; 121: 1-4Crossref PubMed Google Scholar the progress to advanced phases is usually achieved through multiple customised strategies in the different layers of the community that enable women to thrive and ensure good health; these strategies include widening the scope of maternal health to services including prepregnancy care and long-term postnatal health, preventing non-communicable diseases, protecting women's rights, and eliminating discrimination.7Souza JP Tunçalp Ö Vogel JP et al.Obstetric transition: the pathway towards ending preventable maternal deaths.BJOG. 2014; 121: 1-4Crossref PubMed Google Scholar, 8Filippi V Chou D Barreix M Say L A new conceptual framework for maternal morbidity.Int J Gynaecol Obstet. 2018; 141: 4-9Crossref Scopus (0) Google Scholar Mortality is considered the tip of the iceberg with regard to maternal health care—ie, there are other less obvious outcomes that also need to be addressed. For example, maternal and neonatal morbidity also need to be measured and considered. Additionally, challenges in the provision of heath care might arise as a result of increases in obesity, older age during pregnancy, and increases in the size of vulnerable populations (eg, migrants). Ultimately, the need for women-centred care should be emphasised, with integrated services available if complications arise and mechanisms to improve quality of care.8Filippi V Chou D Barreix M Say L A new conceptual framework for maternal morbidity.Int J Gynaecol Obstet. 2018; 141: 4-9Crossref Scopus (0) Google Scholar, 9Kobeissi L Pyone T Moran AC Strong KL Say L Scaling up a monitoring and evaluation framework for sexual, reproductive, maternal, newborn, child, and adolescent health services and outcomes in humanitarian settings: a global initiative.Dialogues Health. 2022; 1100075Crossref Google Scholar, 10Firoz T McCaw-Binns A Filippi V et al.A framework for healthcare interventions to address maternal morbidity.Int J Gynaecol Obstet. 2018; 141: 61-68Crossref PubMed Scopus (39) Google Scholar Not all these aspects could be properly addressed by the assessment of the five-phase mortality transition model, and should be considered in future evaluations. We declare no competing interests. Maternal mortality, stillbirths, and neonatal mortality: a transition model based on analyses of 151 countriesThe five-phase maternal mortality, stillbirth, and neonatal mortality transition model can be used to benchmark the current indicators in comparison to typical patterns in the transition at national or sub-national level, identify outliers to better assess drivers of progress, and inform strategic planning and investments towards Sustainable Development Goal targets. It can also facilitate programming for integrated strategies to end preventable maternal mortality and neonatal mortality and stillbirths. Full-Text PDF Open Access